Provider Demographics
NPI:1750087417
Name:ELLIS, DELORIA JEAN (ALC)
Entity type:Individual
Prefix:
First Name:DELORIA
Middle Name:JEAN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 PATTON RD SW APT M
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805-4834
Mailing Address - Country:US
Mailing Address - Phone:334-560-6024
Mailing Address - Fax:
Practice Address - Street 1:8089 HIGHWAY 72 W STE D
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-9531
Practice Address - Country:US
Practice Address - Phone:256-489-0025
Practice Address - Fax:256-325-0429
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC4153A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health